CurrentCapital BluecrossPolicy N/A

Continuous Glucose Monitors (CGMs) prior authorization and benefit limits

Defines prior authorization criteria and member benefit limits (units per period) for multiple CGM systems, list of applicable NDCs/GPIs/MSC products, and system setup limits for receivers, transmitters, sensors, monitors, kits and readers.

Policy Summary

PayerCapital Bluecross

PolicyContinuous Glucose Monitors (CGMs) prior authorization and benefit limits

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIf requested quantity exceeds the program quantity limit, submit supporting clinical information for prior authorization; otherwise ensure claims respect the listed product-specific benefit limits.

POLICY UPDATE CHANGES

No material clinical/coverage changes in this update.

~40Unique NDC/GPIs/MSC items listed

1Primary PA criterion count

365Common receiver/transmitter/monitor day limit

Policy summary

Subject: Continuous Glucose Monitors (CGMs) prior authorization and benefit limits. Status: CURRENT. This policy defines prior authorization criteria and member benefit/unit limits for multiple CGM systems and components (including Dexcom G6/G7, Guardian/Minimed, Simplera Sync, Enlite and related products). It maps applicable NDCs, GPIs and MultiSource Code (MSC) product names (see listed NDCs/GPIs/MSC product names) to the policy limits and summarizes common system setup limits such as 1 receiver / 365 days, 1 transmitter / 365 days (some products 1 transmitter / 90 days), 4 sensors / 28 days or alternate sensor limits (3/30 or 5/30 depending on product), 1 monitor / 365 days, and 1 reader/kit / 365 days. The primary PA criterion: approval if the requested quantity does NOT exceed the program quantity limit or if supporting information is provided for quantities above the limit.